This report focuses on racialized immigrant women who have experienced intimate violence and their access to, and encounters with, the health care system. In particular, the report focuses on the formal health care system centering on physicians' private practices, walk-in clinics and hospitals where women are likely to seek services for violence-related health care. The report reviews some of the current literature in the area and identifies key variables that contribute to immigrant women's vulnerability to violence and lack of access to health care. The response of health care professionals to women who have experienced violence is also examined.

Findings of the literature review suggest that immigrant women of colour are at risk of violence, and that the risk they face stems from their structural location in society. Lack of dominant language skills, accreditation of their qualifications, and the prevalence of racism and sexism, contribute to the deskilling of these women and their subsequent ghettoization in occupations that are dangerous and unprotected. As immigrants, they experience the trauma of migration which includes dislocation, role overload, as well as role reversal. The latter occurs as a result of their more rapid employment in the labour force, albeit in occupations that are downwardly mobile and marginalized. The isolation that immigrant women experience has been identified as a key factor contributing to their risk. It is exacerbated by their dependent status on their spouses, as underscored by immigration legislation, resulting in an unequal power relation and the potential for abuse within the family.

This report details a thematic analysis of information derived from: (a) an environmental scan consisting of telephone interviews with twenty-one organizations around the province of British Columbia; (b) individual interviews with six key informants and service providers working with immigrant women; (c) focus groups with immigrant women of colour who have experienced abuse, as well as a focus group with bilingual and bicultural service providers; and (d) individual interviews with immigrant women from racialized communities. The questions asked in the interviews and focus groups were developed in concert with frontline anti-violence workers and the findings of the literature review.

In total, twenty-seven informants and service providers working in different organizations were contacted for the interviews and consultations. The interviews were conducted by telephone, while key informants were consulted in person. Twelve of the interviewees were from transition houses and shelters, three worked at rape crisis centres or at women's centres, four worked at immigrant settlement service organizations, four were in hospital-based services or clinics, two worked in social service organizations (i.e., neighbourhood houses), one worked in a program at the Ministry for Children and Families, and one was a regional health board multicultural worker.

The focus group with immigrant women who had experienced abuse consisted of five women from diverse backgrounds. The focus group with bicultural and bilingual service providers consisted of eleven women, most of whom were immigrant women of colour. In addition, ten individual interviews with immigrant women of colour were conducted to supplement the focus group data. These data were also analyzed in terms of emergent themes.

Analysis of the results indicate that for the most part, physician response to women who have been abused is inadequate. However, the quality of physician response was considerably better in those sites where screening protocols for domestic violence were in place. For racialized women - immigrant women of colour and Aboriginal women - the response was of poorer quality and influenced by stereotypes about violence within these groups. Interviewees and focus group participants noted that physicians often attribute violence to cultural groups on the assumption that these communities are inherently violent. Cultural racism is used to explain these perceptions and the resulting differential treatment of racialized women.

Issues concerning disclosure of violence are discussed within the context of immigrant women of colour's structural location in society. Living in a society where they are constantly marginalized and excluded forces women to turn to their families and communities for support. Within such a context, disclosure becomes difficult for fear that it might result in ostracization and exclusion from the community. The situation is exacerbated by the current scrutiny of immigrants of colour and their stereotyping and criminalization. It is also aggravated by the power and control dynamics inherent in the abusive relationship whereby spouses use the threat of deportation to silence women from disclosing.

Language barriers often force women to turn to physicians who share the same cultural and racial background. The findings indicate that most women consult physicians who are chosen by their spouses. In the case of an abusive relationship, women are discouraged from disclosing for fear that their confidences might be breached by the physician who has a prior relationship with the spouse, and who may also be seeing the immediate and extended family. Service providers observed that abusive spouses and children often act as interpreters for women, thus contributing to women's reluctance to disclose abuse. Participants mentioned that male physicians who share the same cultural and racial background as their women patients are reluctant to get involved in domestic violence cases. In contrast, female physicians were more likely to be involved and tended to show greater empathy. This gender difference was also observed in the environmental scan which focused on white, Aboriginal and immigrant women.

Focus group participants and interviewees continually emphasized the lack of time that physicians provide to patients. They stated that a trusting relationship is most conducive to disclosure. In contrast they observed that physicians tend to focus on the rapid processing of patients. This effectively limits the potential of developing trust and communicates to women that their concerns are not important. The trivializing of women's health concerns and the reluctance of physicians to examine these concerns within the context of women's lives was also identified as major shortcomings. Further, the linkages between violence and mental health are not explored by most physicians in their treatment of women who have been abused.

Recommendations arising from this research emphasize the need for health care providers to be more educated and aware of the health impacts of violence. Recommendations emerging from the focus group and interviews suggest a need for physicians to employ a socio-ecological model in understanding and treating violence. Such a model includes an examination of societal, institutional and individual factors that impact on health. The trauma of migration, racism, marginalization and exclusion, and the dynamics of intimate forms of violence need to be considered in tandem in assessing an immigrant woman of colour's health care needs. Further, recommendations outline the need for accredited interpretation services that can be utilized by physicians to better serve the needs of immigrant women of colour. Other recommendations focus on the need to reduce risk factors such as isolation through active outreach strategies and the deployment of public health or community nurses. Fluency in the particular language combined with knowledge about the community's social and historical experiences is a necessity. As such, it is recommended that nurses and outreach workers be selected from communities of colour.

Finally, recommendations concerning the production and distribution of information about the health impacts of violence focus on the dissemination of this information in multilingual formats within schools, places of worship, community centres, specialized grocery stores, immunization clinics, as well as in spaces that are commonly frequented by women. Community and mainstream media were identified as some of the most effective ways of distributing information pertaining to violence and health.

A punch in the eye or a kick in the stomach is probably the same no matter what colour you are or what language is being shouted at the time.
Christine Rasche (1988:165)

The conscious or unconscious behaviours of people whose culture has the power to define service policies and practice may cause those from other cultural groups to feel powerlessness, anger and humiliation often resulting in avoidance of the service. In Maori that response is called whakam, to make things white, an emotional whiteout.
Irihapeti Ramsden (1993:7)

This report examines the health care issues faced by immigrant women of colour who have experienced intimate violence. It seeks to locate their experiences within the nexus of the social, economic and political conditions that structure the lives of immigrant women of colour in Canada. While government policy defines immigrants as those who are not born in Canada (see for instance, Kinnon, 1999),⁽¹⁾ the focus of this investigation is narrower in that the examination is limited to racialized women of colour who are not born in Canada. Further, the investigation is limited to those women who have obtained legal status and thus does not include the barriers faced by undocumented women, migrant workers, foreign students or women who are in Canada on a visitor's visa.

While the health care system in totality is diverse in its orientations, this report focuses on immigrant women of colour who have experienced violence and their encounters with a particular domain of the health care system - namely, the medical professionals who work in the context of private practice, walk-in clinics and emergency rooms. A further objective is to outline recommendations that would ameliorate the conditions of immigrant women of colour and enhance their access to health care, and more specifically, medical care. This objective is in keeping with policies arguing for women-centred care (Hills & Mullett, 1998), the Ottawa Charter (Canadian Public Health Association, 1994),⁽²⁾ as well as Health Canada's Population Health Framework which identifies gender as a determinant of health.

The report begins with a review of the literature focusing on the particular vulnerabilities of immigrant women. It draws on studies conducted in the United States, Britain, and Australia in order to augment Canadian studies. The review includes an identification of some of the health impacts of intimate violence and the particular barriers that women who have experienced violence encounter in accessing health care. While this review of the literature is not exhaustive, it highlights the common problems that confront racialized immigrant women in a variety of different contexts.

Subsequent sections of this report detail the findings from an environmental scan obtained from interviews and consultations with service providers and key informants, as well as focus groups and interviews conducted with racialized immigrant women and bilingual and bicultural service providers. The report concludes with recommendations drawn from the literature, interviews and focus groups, as well as those articulated by immigrant women of colour survivors of violence who participated in this study.

STRUCTURAL VERSUS ETHNO-SPECIFIC ANALYSIS

While this report draws from the various ethno-specific studies cited in the literature, it does not focus on the cultural cosmology of particular groups or the particular expressions of gendered violence that might occur in these groups. Too often, such analyses have been used in both scholarly and popular media to reinforce stereotypes about immigrant women of colour.⁽³⁾ In keeping with the processes of racialization where some groups are marked because of their imputed or biological differences, and the ideology of systemic racism which attributes these groups with negatively valued traits, it becomes incumbent on those conducting socially responsible research not to feed into the stereotypes.

The tendency of ethno-specific research has been to focus on the culture of particular groups. While such an approach has validity, "culture talk is a double-edged sword" (Razack, 1994:986). It can reify cultures as static entities, obscure the relations of power within and outside of the cultural group, and fail to consider the relational aspects of cultural identity (Abraham, 1995) as emerging from a migrant, diasporic existence (Dossa, 1999). Add to this the contextual backdrop of systemic and everyday racism (Essed, 1990) and the focus on culture quickly becomes one of implicitly or explicitly comparing a backward, traditional and oppressive cultural system to the modern, progressive and egalitarian culture assumed of the West (Burns, 1986; Lai, 1986; Jiwani, 1993; Said, 1979; Thobani, 1998). Such an approach can result in the production of cultural prescriptions which further entrench stereotypic representations of particular ethnic groups (Razack, 1998).

This is not to suggest that an ethno-specific analysis would not yield a representative rendering of the issues and barriers faced by a particular group of women. However, an adequate ethno-specific analysis would have to employ interpretive methodologies grounded in a theoretical framework that would draw out the 'thick' description (Geertz, 1973) of immigrant women's lives (e.g. Dossa, 1999). Such a methodology requires time and has its own issues with regard to representational politics (Bannerji, 1987; 1993). That is not the purpose of this report. The aim in the present context is to outline the impact of structural forces and the barriers they produce which impede and curtail racialized immigrant women's access to formal health care (medical care).

^3. For an example of the ways in which occurrences of gender-based violence have been used to entrench stereotypes about particular groups, see Jiwani (1998), and Jiwani & Buhagiar, (1997).